BOSTON -- Provider education on the dosing and administration of epinephrine improved knowledge among healthcare professionals at three community hospitals in Cleveland about how to properly treat life-threatening allergic reactions, a researcher found.Mean test scores for knowledge of anaphylaxis increased 31% from baseline among attending physicians, residents, medical students, and nurses, reported John Johnson, DO, of University Hospitals Cleveland Medical Center.

At a presentation at the American College of Allergy, Asthma & Immunology annual meeting, Johnson said that anaphylaxis is often misdiagnosed because there is no definitive diagnosis, and errors in epinephrine dosage, concentration, and treatment route are common, even among healthcare professionals.

Johnson said "observations from our inpatient consult service" suggested there were problems. "We want to have epinephrine ready to go for patients, but we often get the wrong vial sent to us by pharmacy for the proper concentration of epinephrine," he said.He added that he'd observed many emergency departments were not ordering a tryptase test, which can help confirm a diagnosis of anaphylaxis, and "by the time someone thinks of ordering it, the patient was way past the 2-hour mark."A pre-test, learning module and post-test to track knowledge improvement were administered to 91 nurses, 51 residents, 31 medical students and 16 attending physicians at St. John Medical Center, Richmond and Bedford Hospitals, all affiliated with University Hospitals Cleveland.

The pre- and post-test did not have the same questions. He added that because "not everyone goes to medical school," they made the language of the questions "friendly to all" -- for example "stomach cramping" instead of "abdominal pain."

Multiple-choice questions addressed the following:Time to onset and signs and symptoms of anaphylaxisLeast likely causes of anaphylaxisRoute of administration for epinephrineProper dosing of epinephrineOverall, a little under two-thirds of questions were answered correctly on the pre-test, while 93% of questions were answered correctly on the post-test. Johnson's team noted that pre-test scores were positively correlated with years of experience among both physicians and physicians-in-training. However, all groups of healthcare professionals had significant improvements on their post-test scores -- with groups ranging from a 27% to a 32% improvement in scores.

Proper dosing of epinephrine (1: 1,000 [intramuscular] IM route) was the question that was most commonly answered incorrectly among all groups. Route of administration was also a point of contention, with attending physicians and nurses preferentially choosing intravenous over intramuscular epinephrine for anaphylaxis, "if a patient already had intravenous access." However, the authors added that selecting the correct dose and administration route on the pre-test did not improve with years of experience.

At the presentation, one clinician said education is thought to be the least effective method of quality improvement, and asked if "another add-on" might be needed.Johnson said that "continued persistence" was the answer -- including doing grand rounds and having greater prevalence in the communities.

"It's going to be on us to educate people. We've been doing this for years and you'd think this would've had to change, but it hasn't," he commented.

Johnson said that he hoped to go back and reassess these hospitals after a 6 month period to see if the learning module made a difference in the community and improved the overall care that patients are getting. Another next step would be to try and expand this program into other areas of the community, like the school system.

"We want people to be exposed in the proper way and not have this sterile environment that we're living in where everyone is developing allergies," he said.

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